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Cited by 65Ovarian function and disordersDermatologic Treatments and ResearchHair Growth and Disorders

Interventions for hirsutism (excluding laser and photoepilation therapy alone)

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van Zuuren, Esther J, Fedorowicz, Zbys, Carter, Ben, Pandis, Nikolaos·2015·Cochrane Database of Systematic Reviews
DOI 10.1002/14651858.cd010334.pub2PMC PMC6481758
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Abstract

BACKGROUND: Hirsutism occurs in 5% to 10% of women of reproductive age when there is excessive terminal hair growth in androgen-sensitive areas (male pattern). It is a distressing disorder with a major impact on quality of life. The most common cause is polycystic ovary syndrome. There are many treatment options, but it is not clear which are most effective. OBJECTIVES: To assess the effects of interventions (except laser and light-based therapies alone) for hirsutism. SEARCH METHODS: We searched the Cochrane Skin Group Specialised Register, CENTRAL (2014, Issue 6), MEDLINE (from 1946), EMBASE (from 1974), and five trials registers, and checked reference lists of included studies for additional trials. The last search was in June 2014. SELECTION CRITERIA: Randomised controlled trials (RCTs) in hirsute women with polycystic ovary syndrome, idiopathic hirsutism, or idiopathic hyperandrogenism. DATA COLLECTION AND ANALYSIS: Two independent authors carried out study selection, data extraction, 'Risk of bias' assessment, and analyses. MAIN RESULTS: We included 157 studies (sample size 30 to 80) comprising 10,550 women (mean age 25 years). The majority of studies (123/157) were 'high', 30 'unclear', and four 'low' risk of bias. Lack of blinding was the most frequent source of bias. Treatment duration was six to 12 months. Forty-eight studies provided no usable or retrievable data, i.e. lack of separate data for hirsute women, conference proceedings, and losses to follow-up above 40%.Primary outcomes, 'participant-reported improvement of hirsutism' and 'change in health-related quality of life', were addressed in few studies, and adverse events in only half. In most comparisons there was insufficient evidence to determine if the number of reported adverse events differed. These included known adverse events: gastrointestinal discomfort, breast tenderness, reduced libido, dry skin (flutamide and finasteride); irregular bleeding (spironolactone); nausea, diarrhoea, bloating (metformin); hot flushes, decreased libido, vaginal dryness, headaches (gonadotropin-releasing hormone (GnRH) analogues)).Clinician's evaluation of hirsutism and change in androgen levels were addressed in most comparisons, change in body mass index (BMI) and improvement of other clinical signs of hyperandrogenism in one-third of studies.The quality of evidence was moderate to very low for most outcomes.There was low quality evidence for the effect of two oral contraceptive pills (OCPs) (ethinyl estradiol + cyproterone acetate versus ethinyl estradiol + desogestrel) on change from baseline of Ferriman-Gallwey scores. The mean difference (MD) was -1.84 (95% confidence interval (CI) -3.86 to 0.18).There was very low quality evidence that flutamide 250 mg, twice daily, reduced Ferriman-Gallwey scores more effectively than placebo (MD -7.60, 95% CI -10.53 to -4.67 and MD -7.20, 95% CI -10.15 to -4.25). Participants' evaluations in one study with 20 participants confirmed these results (risk ratio (RR) 17.00, 95% CI 1.11 to 259.87).Spironolactone 100 mg daily was more effective than placebo in reducing Ferriman-Gallwey scores (MD -7.69, 95% CI -10.12 to -5.26) (low quality evidence). It showed similar effectiveness to flutamide in two studies (MD -1.90, 95% CI -5.01 to 1.21 and MD 0.49, 95% CI -1.99 to 2.97) (very low quality evidence), as well as to finasteride in two studies (MD 1.49, 95% CI -0.58 to 3.56 and MD 0.40, 95% CI -1.18 to 1.98) (low quality evidence).Although there was very low quality evidence of a difference in reduction of Ferriman-Gallwey scores for finasteride 5 mg to 7.5 mg daily versus placebo (MD -5.73, 95% CI -6.87 to -4.58), it was unlikely it was clinically meaningful. These results were reinforced by participants' assessments (RR 2.06, 95% CI 0.99 to 4.29 and RR 11.00, 95% CI 0.69 to 175.86). However, finasteride showed inconsistent results in comparisons with other treatments, and no firm conclusions could be reached.Metformin demonstrated no benefit over placebo in reduction of Ferriman-Gallwey scores (MD 0.05, 95% CI -1.02 to 1.12), but the quality of evidence was low. Results regarding the effectiveness of GnRH analogues were inconsistent, varying from minimal to important improvements.We were unable to pool data for OCPs with cyproterone acetate 20 mg to 100 mg due to clinical and methodological heterogeneity between studies. However, addition of cyproterone acetate to OCPs provided greater reductions in Ferriman-Gallwey scores.Two studies, comparing finasteride 5 mg and spironolactone 100 mg, did not show differences in participant assessments and reduction of Ferriman-Gallwey scores (low quality evidence). Ferriman-Gallwey scores from three studies comparing flutamide versus metformin could not be pooled (I² = 62%). One study comparing flutamide 250 mg twice daily with metformin 850 mg twice daily for 12 months, which reached a higher cumulative dosage than two other studies evaluating this comparison, showed flutamide

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Authors
van Zuuren, E. J., Fedorowicz, Z., Carter, B., & Pandis, N.
Affiliations
  • Leiden University Medical Center; Department of Dermatology; PO Box 9600 B1-Q Leiden Netherlands 2300 RC
  • Cochrane (GB)
  • King's College London (GB)
  • University of Bern (CH)
ORCID
Venue
Cochrane Database of Systematic Reviews
Publisher
Wiley
Published
2015-04-28
Volume
2017
Issue
5
Pages
CD010334-CD010334
ISSN
  • 1361-6137 (ISSN-L)
  • 1465-1858
DOI
10.1002/14651858.cd010334.pub2
PMC
PMC6481758
OpenAlex
W1797553927
Cited by
65
References
366
Citations by year
2026: 1 · 2025: 4 · 2024: 5 · 2023: 6 · 2022: 4 · 2021: 6 · 2020: 5 · 2019: 7 · 2018: 3 · 2017: 9 · 2016: 9 · 2015: 3 · 2012: 2
FWCI
1.21
Type
journal article
Language
en
Open access
Locations
  • Cochrane Database of Systematic Reviews (publishedVersion)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
  • Data Archiving and Networked Services (DANS) (submittedVersion)
  • Leiden Repository (Leiden University) (submittedVersion)
  • Bern Open Repository and Information System (University of Bern) (submittedVersion, other-oa)
  • ORCA Online Research @Cardiff (Cardiff University) (submittedVersion)
Topics
  • Health Sciences › Medicine › Reproductive Medicine › Ovarian function and disorders
  • Health Sciences › Medicine › Dermatology › Dermatologic Treatments and Research
  • Health Sciences › Medicine › Urology › Hair Growth and Disorders
Keywords
hirsutism, polycystic ovary syndrome, idiopathic hirsutism, androgenetic alopecia, androgen deprivation therapy, spironolactone, flutamide, finasteride, metformin, GnRH analogues, oral contraceptives, topical retinoids, topical corticosteroids
MeSH terms
Adult, Eflornithine, Androgen Antagonists, Contraceptive Agents, Female, Drug Combinations, Ethinyl Estradiol, Female, Flutamide, Hirsutism, Humans, Hypoglycemic Agents, Metformin, Quality of Life, Spironolactone, Body Mass Index, Randomized Controlled Trials as Topic, Desogestrel, Cyproterone Acetate, Finasteride, 5-alpha Reductase Inhibitors

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